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k APPLICATION FOR PERMITS <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ' I. ENVIRONMENTAL HEALTH DIVISION NOW Ot AS_ <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 (\Ja �,�,� `A4 <br /> P O BOX 2009, STOCKTON, CA 95201 G <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin Count for <br /> q y a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address —lL_ S-3 � f707 d 19-`' City Lot Size/Acreage <br /> (yam Owner's Name _ ./J /9 L' / 4�' h 111yA- Address .._r f2 S3 U 7-& <br /> U(Contractor 3 -� Address License No. phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial D Open Bottom E] Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fl Domestic/Private C] Gravel Pack C] Tracy ., �- Type-of Casing Specifications <br /> CI Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I ! Irrigation —Approx.,Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 T r <br /> P Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth 1 Filler Material d Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is <br /> available within-200 feet.] 6- <br /> Installation will serve: Residence J Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cf No. & Length of lines Total length/size ' <br /> FILTER BED 1-1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth E Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin'County <br /> Home owner or licensed agent's signature,'certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." !l <br /> p/ Thea an usi call forsall require�inspections. Complete drawing on rave se side. <br /> Signed Title: ' D <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by ate 22 U <br /> Additional Comments: r <br /> Applicant - Return all copies to: Sea Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-241REV. <br /> EH <br />